Provider Demographics
NPI:1710384235
Name:EAGLE, JENNIFER (CNM, ARNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:EAGLE
Suffix:
Gender:F
Credentials:CNM, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 BROOKEDGE TER
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-6114
Mailing Address - Country:US
Mailing Address - Phone:253-514-1070
Mailing Address - Fax:
Practice Address - Street 1:3801 S KANNER HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4801
Practice Address - Country:US
Practice Address - Phone:772-419-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-26
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11024601363LX0001X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1710384235Medicaid